Healthcare Provider Details

I. General information

NPI: 1770275331
Provider Name (Legal Business Name): SAMANTHA JO CASPER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 S RIDGE RD
GREEN BAY WI
54304-4125
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4888
  • Fax: 920-430-4889
Mailing address:
  • Phone: 920-445-7210
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16276-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: